Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, September 15, 2006

Tales From the Right Lower Quadrant: appendixes I have known. Part one.

Dr. Dunphy (J. Englebert "Bert" Dunphy, Chairman of the Surgery Dep't, UCSF, RIP) used to tell us: when evaluating abdominal pain, never have appendicitis lower than second on your differential. It's a good thought to keep close: whereas classic appendicitis is most often a fairly straightforward bedside-makeable diagnosis, it can do pretty strange things, and be a major diagnostic challenge. Not to mention being the cause of a few good stories.

First, some background: the appendix -- its spanking name is appendix vermiformis, which means wormlike thingy -- looks, in its normal state, like a little worm, 'bout half a night-crawler. Doing nothing that any (reliable) research has ever identified, it hangs down from the cecum like a sad little rat-tail in the right lower part of your belly. Most people never have any reason to know it's there. When they do, in by far the most of cases, it's because it becomes infected: infection of the appendix is called appendicitis.

Your mom may have told you if you swallow cherry pits you'll get appendicits. I know your mom: she wasn't wrong often, but this is one of the times. That rumor may have gotten started because of an item called an appendicolith, which means a stone in the appendix. ("I gave my love a cherry, without a stone... I gave my love a chicken...." etc.) The other, less impressive, name is fecalith. What it is is a piece of stool that got stuck in there and become so inspissated it's like stone. This is one presumed cause of appendicitis; it also can lead to a rare situation of recurring appendicits (more, later.) But the fact is, in most cases there's not an identifiable reason when it happens; and in the vast majority of instances, it's a one-time deal. (I always made a point of telling kids with appendicitis, and their parents, that it's no one's fault: it's nothing they ate, nothing they did. It just happened.)

The gut doesn't have a large trick-bag; meaning, it only has a few ways it can respond to illness, and it doesn't have the sort of pain nerves that allow localization. If I pinch you on your skin, you'd know exactly where, with your eyes closed. Pinch a spot on your intestines, and you'd likely only muster a "yuck." So the early signs of infection or inflammation of one part of the gut have a way of sounding like and feeling like those in another. When appendicitis starts, therefore, it's usually with a vague yucky feeling, loss of appetite, nausea. Pain is hard to put a finger on, at first. It's only when the inflammation progresses to the point that it involves surrounding tissues -- specifically, the parietal peritoneum, which has LOTS of nerves, of the kind the brain can pinpoint -- that the pain begins to localize where the appendix is (or is supposed to "is"), in the right lower abdomen. Typically it takes a half a day or a day for the symptoms to localize. Appendicitis can happen at any age, but is significantly more common in kids (around five years old to teenage, and there's another spike of frequency in us senior citizens.) Luckily, it's rare in babies, which is good: it's hard as hell to diagnose early in them.

As the infection evolves, the appendix gets red and swollen, going from worm-size to -- sometimes -- finger-size. And left to its own devices, the infection eventually rots away all or part of the appendix (gangrenous appendicitis) and it falls apart, allowing the pus inside to leak out. Ruptured appendix, as you've no doubt heard. When that happens, things generally go in one of two ways, depending on several factors, including the location of the tip-end of the appendix: either pus flows all over the place, causing generalized peritonitis, or it gets walled off into an abscess. In the former case, you'll get sick as hell; in the latter, you won't feel great but it's possible to limp along without disaster.

The cecum is always the starting point, anatomically, of the appendix, and the cecum is nearly always situated in the right lower part of the abdomen. But the tip of the appendix can be in a lot of places, depending on its length, and resting place. Some far ends of the thing are way down in the pelvis; some are across to the left, or aiming north. Quite a few take off from the cecum and run backwards behind it, and can go as high as the liver in that "retro cecal" orientation. Major bummer for the victim and his/her surgeon.

OK. So now, assuming you didn't already, you have a background for a few stories I'm going to tell.

20 comments:

I see appendicitis in the office usually a few times a year. Its funny about half the time I know the diagnosis immdiately and send to the er. The other half i usually send to Cat scan and have them sit in radiology while I wait for the answer. Occasionally I get one that has been brewing for a few weeks and has already ruptured yet the patient is only now starting to get sick. Appendicitis really makes me envy surgeons. Talk about cut to cure! Problem + surgery=problem solved. At least most of the time!

I believe masturbating can cause appendicitis. I'm totally serious cause even though im embarrased to admit it, that is what i believe caused mine. but i never told anyone until now. by the way I'm female. And i have paid dearlyCiao

anonymous: cut yourself some slack. Most people masturbate. Few people get appendicitis. I'm guessing earthquakes have happened, fires started, heart attacks occurred while people were doing it. That does not make a connection. If it were the cause, I'd have taken out a million appendixes in my career. Relax. Coincidence: 100% guaranteed.

Thank You Dr. Schwab, i kind of feel better. I'd like to believe there is no connetion between both, since i have paid $$ dearly (and in full) I thought to myself stupid stupid stupid (after i got the hospital bill). If only I could tell you how it all happened and what i felt. Maybe just maybe masturbating may cause appendicitis in women. I think I'm on to something here. Ciao

1.) Great information and stories.2.) Thanks for doing what you do.3.) A doctor such as yourself saved my life when I had a burst appendix. The "story" with mine was it happened while I was in Afganistan. Unfortunately, got a permanent vertical belly scar out of it, but more importantly I'm alive. I never really stopped to think what amazing things surgeons, doctors, and nurses do on a daily basis. God bless!

I need some help. My husband went into the emerge on fri and was diagnosed with it being his appendix.( x-ray,blood,urine,ect) The doc said they would monitor him and the surgeon would do it in the AM. The new AM doc on call (not the surgeon) decided that since the symptoms were getting better, and his white count was down from 19000 to 16000, we should wait it out until it became acute again. Im worried, should it just come out? Why did it get better. It is now 3 days later, he still has pain, usually if he bends or coughs, but his fever is gone. Should we wait?? No one else I talk to thinks we should wait. The doc said "come back when you are in excruciating doubled over pain" Problem is Jason has an incredible high pain tolerance. I have seen him put his own dislocated thumb back in place. YUCK! Thanks

Hi Dr. Schwab. Your blog is so informative, I enjoy it immensly. On a personal note, I had an appendectomy done in the 80's for typical symptoms of appendicitis. The surgeon said the appendix was not inflammed but he removed for diagnostic purposes since it was "thickened" He also said I had alot of adhesions which was unusal since this was my first abdominal surgery. He wanted additional consults and tests, but the HMO would not approve them. About 1 year later I began having abdominal pain and was seen by another surgeon who drained an abdominal wall abcess and did a colonoscopy. The surgeon then told me I had "classical Crhons disease. This suprised me as I was 60lbs overweight and this fact was used by the HMO to rule out Crohns.Have you ever done an appendectomy and then later Crohns was discoverd? I am now doing great thanks to immune modifiers and am now very lean.

Yes. It's one of the well-known situations when finding a normal appendix when operating for what appears to be appendicitis. In surgical training, in that situation, we were taught always to inspect the terminal ileum, i.e. the last part of the small bowel, where it joins the colon right next to where the appendix is: often the anatomic signs of Crohn's can be seen, if that's what's going on. The terminal ileum is the most common place for Crohn's to show up.

Hi ive been having right lower side abdominal pain for a few months. Until 2 weeks ago it was just an uncomfortable throb that would last an hour a few times a month until two weeks ago i went to the ER with severe sharp pains in the same area that made me scream. But even that came and went for a few hours. Ct scan at the ER reveild an apendolith but no apendicitis. So the doc said if it got worse to come back. Doing the wait and see aproach. Right before the pain I feel like my apendix moves with every pain and the pain last for a split second. Also i feel cramping in that spot most of the time and today i feel like i have gas pains in that spot that is moving to my belly button,again that pain comes and goes to. But my question is, how often do apendoliths turn into apendicitis with the symptoms I have?

I don't think there's a way to answer your specific question, Ms Ahmed, because whereas there have been some studies of people found to have an asymptomatic appendicolith, I'm not aware of something similar for people who presented with symptoms. I'd guess most people in that category underwent appendectomy.

As to people found incidentally to have an appendicolith, the evidence is that it confers increased risk for developing appendicitis, but isn't an absolute indicator, absent symptoms, for having it removed. So the question in your case is whether your symptoms could be due to the stone. (For the record, I doubt you can actually feel your appendix moving.) Since your symptoms aren't classical for appendicitis, I guess it's hard to say for sure: typically appendicitis is a single steady progression with signs of infection leading to treatment. However, there are cases, as I've written, of recurrent appendicitis wherein symptoms come and go. In my experience those cases have often been associated with appendicolith which, I assume, can sometimes act like a ball valve, plugging up the appendix temporarily but releasing before serious infection occurs.

I can't say if your symptoms are due to the stone or not. The doctors caring for you are better able to make that decision. If those docs haven't included a surgeon, you could consider seeing one. Without the benefit of being able to examine you, especially during an episode, I can't say what I'd recommend. I'd say, in general, that it's possible that what's going on is due to the stone and that appendectomy would end it. It would also reduce risk of future appendicitis. But in your specific case, the decision needs to be between you and your doctors, not a person so far removed as I am.

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What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.